Factors Associated with Antenatal Care Service Utilization Under the Eight-Contact Visit Model in Zanzibar

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Kitange, Henry Mruma, David P. Urassa This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8216138/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 5 You are reading this latest preprint version Abstract Background The World Health Organization (WHO) introduced the eight-contact model of antenatal care (ANC) in 2016 to enhance maternal and perinatal outcomes. Despite widespread implementation, adherence to all eight visits remains suboptimal in many low- and middle-income settings, including Zanzibar. Objective To assess factors associated with utilization of ANC services under the eight-contact model among pregnant women in Zanzibar. Methods A cross-sectional analytical study was conducted among 852 postnatal women attending 18 health facilities across Unguja and Pemba. A structured questionnaire was administered via Open Data Kit (ODK). Data were analyzed using Stata 17. Descriptive statistics summarized participants’ characteristics, while chi-square and logistic regression identified factors independently associated with completing eight or more ANC visits. A p-value < 0.05 was considered statistically significant. Results Only 23.0% of women completed ≥ 8ANC contacts. Early ANC booking before 16 weeks was strongly associated with optimal utilization (AOR = 28.89, 95% CI: 11.02–75.76; p = 0.001). Primigravida women had higher odds of completing eight contacts compared to those with more than four pregnancies (AOR = 24.31, 95% CI: 4.09–144.50; p = 0.001). Higher household income (> 1,000,000 TZS/month) was also associated with optimal utilization (AOR = 1.79, 95% CI: 1.02–3.14; p = 0.042). Partner involvement (AOR = 2.07, 95% CI: 1.26–3.42; p = 0.004) and perception of male-friendly clinic environments (AOR = 2.44, 95% CI: 1.38–4.32; p = 0.002) significantly increased the likelihood of completing eight ANC contacts. Conclusion Completion of the eight-contact ANC model remains low in Zanzibar. Key determinants include timing of ANC initiation, parity, household income, partner support, and clinic environments. Strengthening community awareness on early booking, reducing financial barriers, and promoting male-friendly health services could improve ANC utilization and maternal health outcomes. Antenatal care eight-contact model male involvement utilization Zanzibar Tanzania Background Antenatal care (ANC) is essential for safeguarding maternal and newborn health through early identification and management of pregnancy-related complications. The 2016 WHO recommendation of eight ANC contacts was introduced to strengthen continuity of care, improve the quality of maternal experience, and reduce preventable adverse outcomes ( 1 ). Evidence from global implementation shows that increased contact frequency is associated with reduced perinatal mortality and enhanced pregnancy outcomes ( 2 , 3 ). However, translating these global recommendations into improved outcomes depends on contextual health system realities. In Zanzibar, maternal and newborn health indicators continue to reflect areas of concern. While ANC initiation is high, completion rates remain low. Recent reports indicate that only about 31% of pregnant women complete four or more ANC visits under the previous Focused ANC (FANC) model, and early booking before the first 12–16 weeks of gestation remains below one-third of pregnant women (Zanzibar Health Bulletin 2018). Neonatal mortality in Tanzania stands at approximately 24 deaths per 1,000 live births, and the maternal mortality ratio in Zanzibar is estimated at around 260 per 100,000 live births ( 4 , 5 ). These patterns highlight persistent gaps in continuous maternal care, suggesting barriers beyond mere service availability. Although previous studies in Tanzania and other low- and middle-income countries have identified key determinants of ANC utilization such as education level, socioeconomic status, distance to health facilities, parity, and male partner involvement, most of these studies were conducted within the four-visit model ( 6 , 7 ). As a result, they do not adequately capture behavioral, cultural, and health system factors influencing adherence to the eight-contact ANC schedule, particularly within Zanzibar’s unique sociocultural and health system context. Evidence on what drives or hinders completion of eight contacts in Zanzibar is therefore limited, representing a critical knowledge gap. This study addresses that gap by examining the determinants of ANC service utilization under the eight-contact model in Zanzibar. Specifically, the study assesses how socio-demographic characteristics, geographic accessibility, gestational age at booking, and partner involvement influence completion of recommended ANC contacts. The findings are intended to guide policymakers, maternal health program managers, and development partners in designing targeted, context-appropriate strategies to strengthen ANC uptake, thereby contributing to ongoing RMNCAH priorities and advancing progress toward SDG 3.1 , which seeks to reduce maternal mortality. Methods Study Design and Setting A facility-based cross-sectional study was conducted between July and November 2024 in 18 selected health facilities across Unguja and Pemba Islands. The facilities represented urban and rural settings and both public and private sectors. Study Population and Sampling Participants were postnatal women who had delivered within the past 12 months and attended for child immunization. A multistage stratified random sampling method ensured district-level representation, yielding a total of 852 respondents. We first computed a prevalence-based minimum sample (n = 422) using the single-proportion formula (95% CI, d = 5%); then, to ensure representation across 18 facilities, we set ≥ 40 participants per site (target n = 720). Consecutive enrollment through the study period yielded n = 852, exceeding the minimum and enhancing precision/power for the planned analyses. Data Collection A structured questionnaire adapted from WHO ANC assessment tools was administered via ODK. The tool captured demographic characteristics, partner information, geographic accessibility, and facility-related factors. All items in the ODK questionnaire were programmed as mandatory fields; therefore, the final dataset contained no missing values for the variables used in this analysis, and a complete-case analysis approach was applied. Variables The dependent variable was ANC utilization (< 8 vs ≥ 8 visits). Independent variables included demographic, Husband/partner-information, geographic, and health facility factors. Partner involvement was assessed using four individual items: whether the woman contacted or informed her partner before attending ANC (Yes/No); the perceived importance of involving the partner before ANC (Yes/No); partner employment status (Employed/Not employed); and perceived partner support toward ANC attendance (Yes/No). These items were analyzed separately and not combined into a composite score. Perception of a male-friendly clinic setting was assessed using a single item asking whether the antenatal clinic environment was perceived as welcoming to men (Yes/No). Data Analysis Data were analyzed using STATA version 17. Descriptive statistics were used to summarize categorical variables using frequencies and percentages. Bivariate associations between independent variables and ANC utilization were assessed using the chi-square test. Variables with p < 0.05 in the bivariate analysis were included in the multivariable logistic regression model. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported to determine the strength and direction of associations. For all categorical independent variables, one category was designated as the reference group for comparison in the regression analysis. Ethical Considerations Ethical approval was obtained from the MUHAS IRB. Permission was granted by the Zanzibar Ministry of Health, and informed consent was obtained from all participants. Results Most respondents were aged 20–24 years, married, and had secondary school education. 28.5% were employed, Majority (60.5%) of women had a house hold income less than 500,000 TZS per month, Urban residence accounted for 32.3% of participants. Overall, 23.0% of women completed eight or more ANC contacts. Early booking before 16 weeks occurred in 47.3%. See Table 1 Table 1 Socio-Demographic Characteristics and ANC Attendance among Participants (N = 852) Variable Category Frequency (n) Percentage (%) Age Group (years) 18–24 272 31.0 25–29 227 26.6 30–34 189 22.2 ≥ 35 164 19.3 Marital Status Married 810 95.1 Not married 42 4.9 Education Level No formal education 59 6.9 Primary 211 24.8 Secondary 516 60.6 College/University 66 7.7 Employment Status Employed 243 28.5 Not employed 609 71.5 Household Monthly Income (TZS) 1,000,000 70 8.2 Place of Residence Urban 275 32.3 Rural 577 67.7 Parity (Number of Pregnancies) 4 176 20.7 Gestational Age at First ANC Visit 27weeks 149 17.5 ANC Contact Completion ≥ 8 contacts (Optimal utilization) 196 23.0 < 8 contacts 656 77.0 Partner Involvement in ANC Involved 779 91.4 Not involved 73 8.6 Perception of Clinic Setting Male-friendly 691 81.1 Not male-friendly 161 18.9 Women residing in Northern A and Western A districts had significantly higher odds of completing ≥ 8 ANC contacts compared to those from Chakechake district (AOR = 5.48, p = 0.003 and AOR = 4.54, p = 0.001, respectively). Women from households earning more than 1,000,000 TZS per month also had increased odds of optimal ANC utilization compared to those earning less than 500,000 TZS (AOR = 1.79, p = 0.042). Although women living in Unguja showed greater ANC utilization in crude analysis, this association was not significant after adjustment (AOR = 1.67, p = 0.086). See Table 2 . Table 2 District-Level Predictors of ANC Utilization Variable Category Crude OR (95% CI) p-value Adjusted OR (95% CI) p-value District Chakechake (Ref) - - - - Northern A 4.90 (1.87–12.82) 0.001 5.48 (1.82–16.50) 0.003 Northern B 1.09 (0.28–4.16) 0.900 1.02 (0.23–4.30) 0.979 Western A 4.60 (1.69–12.47) 0.003 4.54 (1.45–14.20) 0.001 Obstetric characteristics also demonstrated significant associations. Women with fewer than two pregnancies had markedly higher odds of completing eight ANC contacts compared to those with ≥ 5 pregnancies (AOR = 24.31, p = 0.001), and those with 2–4 pregnancies had higher odds as well (AOR = 8.44, p = 0.015). Early ANC booking before 16 weeks was a strong predictor of optimal utilization. Women initiating ANC between 16–27 weeks (AOR = 28.89, p = 0.001) and those booking ≥ 28 weeks (AOR = 4.52, p = 0.003) were significantly less likely to complete the recommended eight visits. Mode of delivery and number of living children were not independent predictors in the adjusted model. See Table 3 . Table 3 Obstetric Predictors of ANC Utilization Variable Category Crude OR (95% CI) p-value Adjusted OR (95% CI) p-value Mode of Delivery Normal (Ref) - - - - Caesarean section 1.71 (1.08–2.71) 0.023 1.62 (0.96–2.74) 0.069 Parity (> 4 pregnancies Ref) < 2 pregnancies 4.41 (1.98–9.81) 0.001 24.31 (4.09–144.50) 0.001 2–4 pregnancies 1.35 (0.61–3.01) 0.468 8.44 (1.50–47.43) 0.015 Gestational Age at Booking < 16 weeks (Ref) - - - - 16–27 weeks 28.21 (11.72–67.92) 0.001 28.89 (11.02–75.76) 0.001 ≥ 28 weeks 4.68 (1.86–11.82) 0.001 4.52 (1.69–12.08) 0.003 Partner-related factors further influenced ANC utilization. Women who perceived contacting their partner before clinic attendance as important had twice the odds of completing ≥ 8 ANC contacts (AOR = 2.07, p = 0.004). Partner employment was also positively associated with optimal utilization (AOR = 1.97, p = 0.042). Additionally, perceiving the ANC clinic environment as male-friendly significantly increased the likelihood of completing eight contacts (AOR = 2.44, p = 0.002). However, simply contacting the partner prior to the visit was borderline and did not reach statistical significance in the adjusted model (AOR = 1.97, p = 0.052). See Table 4 . Table 4 Partner Involvement Predictors of ANC Utilization Variable Category Crude OR (95% CI) p-value Adjusted OR (95% CI) p-value Contacted Partner No (Ref) - - - - Yes 1.97 (0.90–3.60) 0.098 1.97 (0.99–3.92) 0.052 Importance of Contacting Partner No (Ref) - - - - Yes 2.23 (1.41–3.78) 0.001 2.07 (1.26–3.42) 0.004 Partner Employment Not employed (Ref) - - - - Employed 2.05 (1.08–3.89) 0.028 1.97 (1.03–3.77) 0.042 Male-Friendly Clinic No (Ref) - - - - Yes 3.19 (1.85–5.50) 0.001 2.44 (1.38–4.32) 0.002 Discussion Level of utilization and timing of booking The overall 23.0% completion rate for eight or more visits demonstrates limited adherence to the eight-contact model, similar to patterns observed in other sub-Saharan African countries after the WHO’s 2016 recommendation ( 1 , 6 , 7 ). Early initiation of ANC before 16 weeks was observed among 47.3% of women and was strongly associated with completing eight contacts (AOR = 28.89; p = 0.001). Early booking allows adequate time for subsequent scheduled visits and continuous follow-up. Economic and Obstetric factors Household income above 1,000,000 TZS significantly increased the likelihood of completing eight visits (AOR = 1.79; p = 0.042). Economic stability enhances the ability to meet indirect costs such as transportation, opportunity costs of time, and additional medical expenses ( 8 – 10 ). Similarly, women with fewer than two pregnancies were more likely to complete optimal ANC visits (AOR = 24.31; p = 0.001). Primigravida women often demonstrate higher motivation and health-seeking behavior due to novelty and perceived risk of first pregnancy, findings also noted in Tanzania mainland and Ethiopia ( 11 , 12 ). Partner involvement and male-friendly environments Partner involvement showed a positive association with ANC utilization (AOR = 2.07; p = 0.004). Women whose partners were employed (AOR = 1.97; p = 0.042) and those who perceived ANC clinics as male-friendly (AOR = 2.44; p = 0.002) had higher odds of completing the eight visits. These findings underscore the role of male participation in promoting maternal health utilization. Supportive partners can provide financial, emotional, and logistical support, and their engagement enhances joint decision-making on maternal care. Similar conclusions have been reported in studies conducted in Tanzania, Ethiopia, Nigeria and Kenya, which highlighted male involvement as a determinant of adherence to ANC schedules ( 13 – 16 ). As a cross-sectional study, causality cannot be inferred. The facility-based sampling may limit generalizability to women who do not attend postnatal or ANC services. Self-reported responses may also be subject to recall or social desirability bias. Conclusion This study demonstrates that ANC utilization under the eight-contact model remains suboptimal in Zanzibar, with notable socioeconomic and behavioral disparities. Early ANC booking, lower parity, higher household income, and male involvement were key determinants of completing eight or more ANC contacts. Strengthening systems that encourage early ANC initiation and addressing structural barriers faced by low-income and rural populations are essential to improving uptake. Additionally, incorporating male-friendly approaches within ANC services can enhance partner engagement, continuity of care, and overall maternal health outcomes, supporting national progress toward achieving the WHO-recommended eight-contact standard. Policy Implications The Ministry of Health, in collaboration with Council Health Management Teams (CHMTs), should strengthen community health education emphasizing early ANC booking before 16 weeks and consistent follow-up throughout pregnancy. Primary health facilities should adopt structured male-involvement strategies such as couple-focused ANC sessions, partner invitation messages, flexible clinic hours for working partners, and creation of male-friendly waiting spaces. Expanding community-based health insurance and addressing transport and access barriers in rural areas may further improve ANC completion rates. Recommendations for Practice Strengthen early pregnancy detection and referral pathways through Community Health Volunteers, TBAs, and RCH educators. Integrate partner engagement and counseling into routine ANC service delivery at facility level. Train healthcare providers on gender-sensitive communication and partner-inclusive counseling techniques. Implement follow-up mechanisms such as appointment books, SMS reminders, or digital tracking systems to support women who book late or miss scheduled contacts. Future Research Conduct qualitative studies to explore sociocultural norms, household power dynamics, and partner decision-making roles influencing ANC attendance. Evaluate the effectiveness of male-inclusive ANC models and partner education interventions on adherence to the eight-contact schedule. Assess health system-level factors—including staffing capacity, clinic workflow, and waiting time—and their influence on ANC continuity and patient experience. List of Abbreviation ANC Antenatal Care HF Healthcare Facilities LMICs Low- and Middle-Income Countries MUHAS Muhimbili University of Health and Allied Science NHIF National Health Insurance Fund PH Public Health PHCC Primary Health Care Center PHCU Primary Health Care Unit PHCU + Primary Health Care Units plus RCH Reproductive and Child health SPHSS School of Public Health and Social Sciences Tsh Tanzanian Shillings WHO World Health Organization ZHSF Zanzibar Health Service Fund Declarations Ethical Approval and Consent to Participate Ethical approval for this study was obtained from the Institutional Review Board of the Muhimbili University of Health and Allied Sciences (Ref: DA.282/298/01.C/2258). Permission to conduct the study and collect data was granted by the Zanzibar Health Research Institute (Ref: ZAHREC/02/ST/JULY/2024/155). All participants provided informed consent prior to participation. The study was conducted in accordance with the Declaration of Helsinki and all relevant guidelines and regulations . Consent Process Each participant provided verbal consent after being briefed on the study’s purpose before the interview. All information obtained from the participant were handled with utmost confidentiality. Consent to publication “Not applicable” Competing Interest The authors confirm, that they have no competing interests. Funding This study received no external funding, and all operational costs were covered by the author. Availability of Data Materials The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Authors’ Contributions BK: Study concept and design, manuscript drafting, statistical analysis and data interpretation. DU: Study Supervision HM: Study Supervision All authors have reviewed and approved the final version of this manuscript, including authorship References World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016. UNICEF. Antenatal Care [Internet]. New York. 2024 [cited 2025 Nov 11]. Available from: https://data.unicef.org/topic/maternal-health/antenatal-care/ Tekelab T, Chojenta C, Smith R, Loxton D. The impact of antenatal care on neonatal mortality in sub-Saharan Africa: A systematic review and meta-analysis. PLoS ONE. 2019;14(9). Macrotrends macrotrends. 2021. Tanzania Maternal Mortality Rate 2000–2021 | MacroTrends. Zanzibar, Reproductive. Maternal, Newborn, Child and Adolescent Health Strategic Plan. 2023;(April 2019). MoHCDGEC. Tanzania Demographic and Health Survey and Malaria Indicator Survey. Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC). 2015. Ekholuenetale M. Prevalence of Eight or More Antenatal Care Contacts: Findings From Multi-Country Nationally Representative Data. Glob Pediatr Health. 2021;8. Yang Y, Yu M. Disparities and determinants of maternal health services utilization among women in poverty-stricken rural areas of China: a cross-sectional study. BMC Pregnancy Childbirth [Internet]. 2023;23(1):1–14. Available from: https://doi.org/10.1186/s12884-023-05434-7 Ochako R, Fotso JC, Ikamari L, Khasakhala A. Utilization of maternal health services among young women in Kenya: Insights from the Kenya Demographic and Health Survey, 2003. BMC Pregnancy Childbirth. 2011;11. Njiku F, Wella HL, Sariah A, Protas J. Prevalence and factors associated with late antenatal care visit among pregnant women in Lushoto, Tanzania. Tanzan J Health Res. 2017;19(3). Muniro Z, Tarimo CS, Mahande MJ, Maro E, McHome B. Grand multiparity as a predictor of adverse pregnancy outcome among women who delivered at a tertiary hospital in Northern Tanzania. BMC Pregnancy Childbirth. 2019;19(1). Yaya S, Bishwajit G, Ekholuenetale M, Shah V, Kadio B, Udenigwe O. Timing and adequate attendance of antenatal care visits among women in Ethiopia. PLoS ONE. 2017;12(9). Mangeni JN, Mwangi A, Mbugua S, Mukthar VK. Male involvement in maternal healthcare as a determinant of utilisation of skilled birth attendants in kenya. East Afr Med J. 2012;89(11). Mohammed BH, Johnston JM, Vackova D, Hassen SM, Yi H. The role of male partner in utilization of maternal health care services in Ethiopia: A community-based couple study. BMC Pregnancy Childbirth. 2019;19(1). Factors Associated with Male Partner Involvement. in Maternity Care in Mbeya, Tanzania. East Afr Health Res J. 2023;7(2). Iliyasu Z, Abubakar IS, Galadanci HS, Aliyu MH. Birth preparedness, complication readiness and fathers’ participation in maternity care in a northern Nigerian community. Afr J Reprod Health. 2010;14(1). Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8216138","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":565498931,"identity":"e18b0576-af0a-42c8-94f9-ca04db3cba70","order_by":0,"name":"Bernard H. 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The 2016 WHO recommendation of eight ANC contacts was introduced to strengthen continuity of care, improve the quality of maternal experience, and reduce preventable adverse outcomes (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Evidence from global implementation shows that increased contact frequency is associated with reduced perinatal mortality and enhanced pregnancy outcomes (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eHowever, translating these global recommendations into improved outcomes depends on contextual health system realities. In Zanzibar, maternal and newborn health indicators continue to reflect areas of concern. While ANC initiation is high, completion rates remain low. Recent reports indicate that only about 31% of pregnant women complete four or more ANC visits under the previous Focused ANC (FANC) model, and early booking before the first 12\u0026ndash;16 weeks of gestation remains below one-third of pregnant women (Zanzibar Health Bulletin 2018). Neonatal mortality in Tanzania stands at approximately 24 deaths per 1,000 live births, and the maternal mortality ratio in Zanzibar is estimated at around 260 per 100,000 live births (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). These patterns highlight persistent gaps in continuous maternal care, suggesting barriers beyond mere service availability.\u003c/p\u003e \u003cp\u003eAlthough previous studies in Tanzania and other low- and middle-income countries have identified key determinants of ANC utilization such as education level, socioeconomic status, distance to health facilities, parity, and male partner involvement, most of these studies were conducted within the four-visit model (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). As a result, they do not adequately capture behavioral, cultural, and health system factors influencing adherence to the eight-contact ANC schedule, particularly within Zanzibar\u0026rsquo;s unique sociocultural and health system context. Evidence on what drives or hinders completion of eight contacts in Zanzibar is therefore limited, representing a critical knowledge gap.\u003c/p\u003e \u003cp\u003eThis study addresses that gap by examining the determinants of ANC service utilization under the eight-contact model in Zanzibar. Specifically, the study assesses how socio-demographic characteristics, geographic accessibility, gestational age at booking, and partner involvement influence completion of recommended ANC contacts. The findings are intended to guide policymakers, maternal health program managers, and development partners in designing targeted, context-appropriate strategies to strengthen ANC uptake, thereby contributing to ongoing RMNCAH priorities and advancing progress toward \u003cb\u003eSDG 3.1\u003c/b\u003e, which seeks to reduce maternal mortality.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design and Setting\u003c/h2\u003e \u003cp\u003eA facility-based cross-sectional study was conducted between July and November 2024 in 18 selected health facilities across Unguja and Pemba Islands. The facilities represented urban and rural settings and both public and private sectors.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population and Sampling\u003c/h3\u003e\n\u003cp\u003eParticipants were postnatal women who had delivered within the past 12 months and attended for child immunization. A multistage stratified random sampling method ensured district-level representation, yielding a total of 852 respondents. We first computed a prevalence-based minimum sample (n\u0026thinsp;=\u0026thinsp;422) using the single-proportion formula (95% CI, d\u0026thinsp;=\u0026thinsp;5%); then, to ensure representation across 18 facilities, we set\u0026thinsp;\u0026ge;\u0026thinsp;40 participants per site (target n\u0026thinsp;=\u0026thinsp;720). Consecutive enrollment through the study period yielded n\u0026thinsp;=\u0026thinsp;852, exceeding the minimum and enhancing precision/power for the planned analyses.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eA structured questionnaire adapted from WHO ANC assessment tools was administered via ODK. The tool captured demographic characteristics, partner information, geographic accessibility, and facility-related factors. All items in the ODK questionnaire were programmed as mandatory fields; therefore, the final dataset contained no missing values for the variables used in this analysis, and a complete-case analysis approach was applied.\u003c/p\u003e\n\u003ch3\u003eVariables\u003c/h3\u003e\n\u003cp\u003eThe dependent variable was ANC utilization (\u0026lt;\u0026thinsp;8 vs\u0026thinsp;\u0026ge;\u0026thinsp;8 visits). Independent variables included demographic, Husband/partner-information, geographic, and health facility factors.\u003c/p\u003e \u003cp\u003ePartner involvement was assessed using four individual items: whether the woman contacted or informed her partner before attending ANC (Yes/No); the perceived importance of involving the partner before ANC (Yes/No); partner employment status (Employed/Not employed); and perceived partner support toward ANC attendance (Yes/No). These items were analyzed separately and not combined into a composite score.\u003c/p\u003e \u003cp\u003ePerception of a male-friendly clinic setting was assessed using a single item asking whether the antenatal clinic environment was perceived as welcoming to men (Yes/No).\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eData were analyzed using STATA version 17. Descriptive statistics were used to summarize categorical variables using frequencies and percentages. Bivariate associations between independent variables and ANC utilization were assessed using the chi-square test. Variables with p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 in the bivariate analysis were included in the multivariable logistic regression model. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported to determine the strength and direction of associations. For all categorical independent variables, one category was designated as the reference group for comparison in the regression analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003e \u003cstrong\u003eEthical approval\u003c/strong\u003e \u003cp\u003ewas obtained from the MUHAS IRB. Permission was granted by the Zanzibar Ministry of Health, and informed consent was obtained from all participants.\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eMost respondents were aged 20\u0026ndash;24 years, married, and had secondary school education. 28.5% were employed, Majority (60.5%) of women had a house hold income less than 500,000 TZS per month, Urban residence accounted for 32.3% of participants.\u003c/p\u003e \u003cp\u003eOverall, 23.0% of women completed eight or more ANC contacts. Early booking before 16 weeks occurred in 47.3%. \u003cb\u003eSee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio-Demographic Characteristics and ANC Attendance among Participants (N\u0026thinsp;=\u0026thinsp;852)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency (n)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePercentage (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge Group (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18\u0026ndash;24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e272\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25\u0026ndash;29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e227\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e26.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e189\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e22.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e164\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e19.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e810\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e95.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e6.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e24.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e516\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCollege/University\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e7.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment Status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e243\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e28.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e609\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e71.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHousehold Monthly Income (TZS)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;500,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e515\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e60.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e500,000\u0026ndash;1,000,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e267\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;1,000,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePlace of Residence\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e32.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e577\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e67.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eParity (Number of Pregnancies)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e480\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e176\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e20.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational Age at First ANC Visit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;16 weeks (Early booking)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e402\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e47.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;27 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e301\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e35.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;27weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e149\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eANC Contact Completion\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;8 contacts (Optimal utilization)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e196\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e23.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;8 contacts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e656\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e77.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePartner Involvement in ANC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInvolved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e779\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot involved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e8.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePerception of Clinic Setting\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale-friendly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e691\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e81.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot male-friendly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e161\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eWomen residing in Northern A and Western A districts had significantly higher odds of completing\u0026thinsp;\u0026ge;\u0026thinsp;8 ANC contacts compared to those from Chakechake district (AOR\u0026thinsp;=\u0026thinsp;5.48, p\u0026thinsp;=\u0026thinsp;0.003 and AOR\u0026thinsp;=\u0026thinsp;4.54, p\u0026thinsp;=\u0026thinsp;0.001, respectively). Women from households earning more than 1,000,000 TZS per month also had increased odds of optimal ANC utilization compared to those earning less than 500,000 TZS (AOR\u0026thinsp;=\u0026thinsp;1.79, p\u0026thinsp;=\u0026thinsp;0.042). Although women living in Unguja showed greater ANC utilization in crude analysis, this association was not significant after adjustment (AOR\u0026thinsp;=\u0026thinsp;1.67, p\u0026thinsp;=\u0026thinsp;0.086). \u003cb\u003eSee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistrict-Level Predictors of ANC Utilization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistrict\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChakechake (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorthern A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.90 (1.87\u0026ndash;12.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e5.48 (1.82\u0026ndash;16.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNorthern B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.09 (0.28\u0026ndash;4.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.900\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.02 (0.23\u0026ndash;4.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.979\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWestern A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.60 (1.69\u0026ndash;12.47)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.54 (1.45\u0026ndash;14.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eObstetric characteristics also demonstrated significant associations. Women with fewer than two pregnancies had markedly higher odds of completing eight ANC contacts compared to those with \u0026ge;\u0026thinsp;5 pregnancies (AOR\u0026thinsp;=\u0026thinsp;24.31, p\u0026thinsp;=\u0026thinsp;0.001), and those with 2\u0026ndash;4 pregnancies had higher odds as well (AOR\u0026thinsp;=\u0026thinsp;8.44, p\u0026thinsp;=\u0026thinsp;0.015). Early ANC booking before 16 weeks was a strong predictor of optimal utilization. Women initiating ANC between 16\u0026ndash;27 weeks (AOR\u0026thinsp;=\u0026thinsp;28.89, p\u0026thinsp;=\u0026thinsp;0.001) and those booking\u0026thinsp;\u0026ge;\u0026thinsp;28 weeks (AOR\u0026thinsp;=\u0026thinsp;4.52, p\u0026thinsp;=\u0026thinsp;0.003) were significantly less likely to complete the recommended eight visits. Mode of delivery and number of living children were not independent predictors in the adjusted model. \u003cb\u003eSee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eObstetric Predictors of ANC Utilization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMode of Delivery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNormal (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCaesarean section\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71 (1.08\u0026ndash;2.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.62 (0.96\u0026ndash;2.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.069\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParity (\u0026gt;\u0026thinsp;4 pregnancies Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;2 pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.41 (1.98\u0026ndash;9.81)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e24.31 (4.09\u0026ndash;144.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2\u0026ndash;4 pregnancies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.35 (0.61\u0026ndash;3.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.468\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.44 (1.50\u0026ndash;47.43)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.015\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational Age at Booking\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;16 weeks (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16\u0026ndash;27 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28.21 (11.72\u0026ndash;67.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e28.89 (11.02\u0026ndash;75.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026ge;\u0026thinsp;28 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.68 (1.86\u0026ndash;11.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.52 (1.69\u0026ndash;12.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePartner-related factors further influenced ANC utilization. Women who perceived contacting their partner before clinic attendance as important had twice the odds of completing\u0026thinsp;\u0026ge;\u0026thinsp;8 ANC contacts (AOR\u0026thinsp;=\u0026thinsp;2.07, p\u0026thinsp;=\u0026thinsp;0.004). Partner employment was also positively associated with optimal utilization (AOR\u0026thinsp;=\u0026thinsp;1.97, p\u0026thinsp;=\u0026thinsp;0.042). Additionally, perceiving the ANC clinic environment as male-friendly significantly increased the likelihood of completing eight contacts (AOR\u0026thinsp;=\u0026thinsp;2.44, p\u0026thinsp;=\u0026thinsp;0.002). However, simply contacting the partner prior to the visit was borderline and did not reach statistical significance in the adjusted model (AOR\u0026thinsp;=\u0026thinsp;1.97, p\u0026thinsp;=\u0026thinsp;0.052). \u003cb\u003eSee\u003c/b\u003e Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePartner Involvement Predictors of ANC Utilization\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCrude OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContacted Partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.97 (0.90\u0026ndash;3.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.97 (0.99\u0026ndash;3.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImportance of Contacting Partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.23 (1.41\u0026ndash;3.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.07 (1.26\u0026ndash;3.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.004\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartner Employment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot employed (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.05 (1.08\u0026ndash;3.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.028\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.97 (1.03\u0026ndash;3.77)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.042\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale-Friendly Clinic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo (Ref)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.19 (1.85\u0026ndash;5.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.44 (1.38\u0026ndash;4.32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eLevel of utilization and timing of booking\u003c/h2\u003e \u003cp\u003eThe overall \u003cb\u003e23.0%\u003c/b\u003e completion rate for eight or more visits demonstrates limited adherence to the eight-contact model, similar to patterns observed in other sub-Saharan African countries after the WHO\u0026rsquo;s 2016 recommendation (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Early initiation of ANC before 16 weeks was observed among \u003cb\u003e47.3%\u003c/b\u003e of women and was strongly associated with completing eight contacts (AOR\u0026thinsp;=\u0026thinsp;28.89; p\u0026thinsp;=\u0026thinsp;0.001). Early booking allows adequate time for subsequent scheduled visits and continuous follow-up.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEconomic and Obstetric factors\u003c/h2\u003e \u003cp\u003eHousehold income above 1,000,000 TZS significantly increased the likelihood of completing eight visits (AOR\u0026thinsp;=\u0026thinsp;1.79; p\u0026thinsp;=\u0026thinsp;0.042). Economic stability enhances the ability to meet indirect costs such as transportation, opportunity costs of time, and additional medical expenses (\u003cspan additionalcitationids=\"CR9\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). Similarly, women with fewer than two pregnancies were more likely to complete optimal ANC visits (AOR\u0026thinsp;=\u0026thinsp;24.31; p\u0026thinsp;=\u0026thinsp;0.001). Primigravida women often demonstrate higher motivation and health-seeking behavior due to novelty and perceived risk of first pregnancy, findings also noted in Tanzania mainland and Ethiopia (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003ePartner involvement and male-friendly environments\u003c/h2\u003e \u003cp\u003ePartner involvement showed a positive association with ANC utilization (AOR\u0026thinsp;=\u0026thinsp;2.07; p\u0026thinsp;=\u0026thinsp;0.004). Women whose partners were employed (AOR\u0026thinsp;=\u0026thinsp;1.97; p\u0026thinsp;=\u0026thinsp;0.042) and those who perceived ANC clinics as male-friendly (AOR\u0026thinsp;=\u0026thinsp;2.44; p\u0026thinsp;=\u0026thinsp;0.002) had higher odds of completing the eight visits. These findings underscore the role of male participation in promoting maternal health utilization. Supportive partners can provide financial, emotional, and logistical support, and their engagement enhances joint decision-making on maternal care. Similar conclusions have been reported in studies conducted in Tanzania, Ethiopia, Nigeria and Kenya, which highlighted male involvement as a determinant of adherence to ANC schedules (\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAs a cross-sectional study, causality cannot be inferred. The facility-based sampling may limit generalizability to women who do not attend postnatal or ANC services. Self-reported responses may also be subject to recall or social desirability bias.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis study demonstrates that ANC utilization under the eight-contact model remains suboptimal in Zanzibar, with notable socioeconomic and behavioral disparities. Early ANC booking, lower parity, higher household income, and male involvement were key determinants of completing eight or more ANC contacts. Strengthening systems that encourage early ANC initiation and addressing structural barriers faced by low-income and rural populations are essential to improving uptake. Additionally, incorporating male-friendly approaches within ANC services can enhance partner engagement, continuity of care, and overall maternal health outcomes, supporting national progress toward achieving the WHO-recommended eight-contact standard.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003ePolicy Implications\u003c/h2\u003e \u003cp\u003eThe Ministry of Health, in collaboration with Council Health Management Teams (CHMTs), should strengthen community health education emphasizing early ANC booking before 16 weeks and consistent follow-up throughout pregnancy. Primary health facilities should adopt structured male-involvement strategies such as couple-focused ANC sessions, partner invitation messages, flexible clinic hours for working partners, and creation of male-friendly waiting spaces. Expanding community-based health insurance and addressing transport and access barriers in rural areas may further improve ANC completion rates.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations for Practice\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eStrengthen early pregnancy detection and referral pathways through Community Health Volunteers, TBAs, and RCH educators.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eIntegrate partner engagement and counseling into routine ANC service delivery at facility level.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTrain healthcare providers on gender-sensitive communication and partner-inclusive counseling techniques.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eImplement follow-up mechanisms such as appointment books, SMS reminders, or digital tracking systems to support women who book late or miss scheduled contacts.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eFuture Research\u003c/h2\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eConduct qualitative studies to explore sociocultural norms, household power dynamics, and partner decision-making roles influencing ANC attendance.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEvaluate the effectiveness of male-inclusive ANC models and partner education interventions on adherence to the eight-contact schedule.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAssess health system-level factors\u0026mdash;including staffing capacity, clinic workflow, and waiting time\u0026mdash;and their influence on ANC continuity and patient experience.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"List of Abbreviation","content":"\u003cp\u003eANC Antenatal Care\u003c/p\u003e \u003cp\u003eHF Healthcare Facilities\u003c/p\u003e \u003cp\u003eLMICs Low- and Middle-Income Countries\u003c/p\u003e \u003cp\u003eMUHAS Muhimbili University of Health and Allied Science\u003c/p\u003e \u003cp\u003eNHIF National Health Insurance Fund\u003c/p\u003e \u003cp\u003ePH Public Health\u003c/p\u003e \u003cp\u003ePHCC Primary Health Care Center\u003c/p\u003e \u003cp\u003ePHCU Primary Health Care Unit\u003c/p\u003e \u003cp\u003ePHCU\u0026thinsp;+\u0026thinsp;Primary Health Care Units plus\u003c/p\u003e \u003cp\u003eRCH Reproductive and Child health\u003c/p\u003e \u003cp\u003eSPHSS School of Public Health and Social Sciences\u003c/p\u003e \u003cp\u003eTsh Tanzanian Shillings\u003c/p\u003e \u003cp\u003eWHO World Health Organization\u003c/p\u003e \u003cp\u003eZHSF Zanzibar Health Service Fund\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Institutional Review Board of the Muhimbili University of Health and Allied Sciences (Ref: DA.282/298/01.C/2258). Permission to conduct the study and collect data was granted by the Zanzibar Health Research Institute (Ref: ZAHREC/02/ST/JULY/2024/155). All participants provided informed consent prior to participation. The study was conducted \u003cstrong\u003ein accordance with the Declaration of Helsinki and all relevant guidelines and regulations\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach participant provided verbal consent after being briefed on the study\u0026rsquo;s purpose before the interview. All information obtained from the participant were handled with utmost confidentiality.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;Not applicable\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors confirm, that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received no external funding, and all operational costs were covered by the author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data Materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBK:\u0026nbsp;\u003c/strong\u003eStudy concept and design, manuscript drafting, statistical analysis and data interpretation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDU:\u0026nbsp;\u003c/strong\u003eStudy Supervision\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHM:\u0026nbsp;\u003c/strong\u003eStudy Supervision\u003c/p\u003e\n\u003cp\u003eAll authors have reviewed and approved the final version of this manuscript, including authorship\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUNICEF. Antenatal Care [Internet]. New York. 2024 [cited 2025 Nov 11]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://data.unicef.org/topic/maternal-health/antenatal-care/\u003c/span\u003e\u003cspan address=\"https://data.unicef.org/topic/maternal-health/antenatal-care/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTekelab T, Chojenta C, Smith R, Loxton D. The impact of antenatal care on neonatal mortality in sub-Saharan Africa: A systematic review and meta-analysis. PLoS ONE. 2019;14(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMacrotrends macrotrends. 2021. Tanzania Maternal Mortality Rate 2000\u0026ndash;2021 | MacroTrends.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZanzibar, Reproductive. Maternal, Newborn, Child and Adolescent Health Strategic Plan. 2023;(April 2019).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMoHCDGEC. Tanzania Demographic and Health Survey and Malaria Indicator Survey. Ministry of Health, Community Development, Gender, Elderly and Children (MoHCDGEC). 2015.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEkholuenetale M. Prevalence of Eight or More Antenatal Care Contacts: Findings From Multi-Country Nationally Representative Data. Glob Pediatr Health. 2021;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang Y, Yu M. Disparities and determinants of maternal health services utilization among women in poverty-stricken rural areas of China: a cross-sectional study. BMC Pregnancy Childbirth [Internet]. 2023;23(1):1\u0026ndash;14. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/s12884-023-05434-7\u003c/span\u003e\u003cspan address=\"10.1186/s12884-023-05434-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOchako R, Fotso JC, Ikamari L, Khasakhala A. Utilization of maternal health services among young women in Kenya: Insights from the Kenya Demographic and Health Survey, 2003. BMC Pregnancy Childbirth. 2011;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNjiku F, Wella HL, Sariah A, Protas J. Prevalence and factors associated with late antenatal care visit among pregnant women in Lushoto, Tanzania. Tanzan J Health Res. 2017;19(3).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMuniro Z, Tarimo CS, Mahande MJ, Maro E, McHome B. Grand multiparity as a predictor of adverse pregnancy outcome among women who delivered at a tertiary hospital in Northern Tanzania. BMC Pregnancy Childbirth. 2019;19(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYaya S, Bishwajit G, Ekholuenetale M, Shah V, Kadio B, Udenigwe O. Timing and adequate attendance of antenatal care visits among women in Ethiopia. PLoS ONE. 2017;12(9).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMangeni JN, Mwangi A, Mbugua S, Mukthar VK. Male involvement in maternal healthcare as a determinant of utilisation of skilled birth attendants in kenya. East Afr Med J. 2012;89(11).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMohammed BH, Johnston JM, Vackova D, Hassen SM, Yi H. The role of male partner in utilization of maternal health care services in Ethiopia: A community-based couple study. BMC Pregnancy Childbirth. 2019;19(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFactors Associated with Male Partner Involvement. in Maternity Care in Mbeya, Tanzania. East Afr Health Res J. 2023;7(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIliyasu Z, Abubakar IS, Galadanci HS, Aliyu MH. Birth preparedness, complication readiness and fathers\u0026rsquo; participation in maternity care in a northern Nigerian community. Afr J Reprod Health. 2010;14(1).\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antenatal care, eight-contact model, male involvement, utilization, Zanzibar, Tanzania","lastPublishedDoi":"10.21203/rs.3.rs-8216138/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8216138/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003e The World Health Organization (WHO) introduced the eight-contact model of antenatal care (ANC) in 2016 to enhance maternal and perinatal outcomes. Despite widespread implementation, adherence to all eight visits remains suboptimal in many low- and middle-income settings, including Zanzibar.\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eTo assess factors associated with utilization of ANC services under the eight-contact model among pregnant women in Zanzibar.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional analytical study was conducted among 852 postnatal women attending 18 health facilities across Unguja and Pemba. A structured questionnaire was administered via Open Data Kit (ODK). Data were analyzed using Stata 17. Descriptive statistics summarized participants\u0026rsquo; characteristics, while chi-square and logistic regression identified factors independently associated with completing eight or more ANC visits. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eOnly 23.0% of women completed\u0026thinsp;\u0026ge;\u0026thinsp;8ANC contacts. Early ANC booking before 16 weeks was strongly associated with optimal utilization (AOR\u0026thinsp;=\u0026thinsp;28.89, 95% CI: 11.02\u0026ndash;75.76; p\u0026thinsp;=\u0026thinsp;0.001). Primigravida women had higher odds of completing eight contacts compared to those with more than four pregnancies (AOR\u0026thinsp;=\u0026thinsp;24.31, 95% CI: 4.09\u0026ndash;144.50; p\u0026thinsp;=\u0026thinsp;0.001). Higher household income (\u0026gt;\u0026thinsp;1,000,000 TZS/month) was also associated with optimal utilization (AOR\u0026thinsp;=\u0026thinsp;1.79, 95% CI: 1.02\u0026ndash;3.14; p\u0026thinsp;=\u0026thinsp;0.042). Partner involvement (AOR\u0026thinsp;=\u0026thinsp;2.07, 95% CI: 1.26\u0026ndash;3.42; p\u0026thinsp;=\u0026thinsp;0.004) and perception of male-friendly clinic environments (AOR\u0026thinsp;=\u0026thinsp;2.44, 95% CI: 1.38\u0026ndash;4.32; p\u0026thinsp;=\u0026thinsp;0.002) significantly increased the likelihood of completing eight ANC contacts.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCompletion of the eight-contact ANC model remains low in Zanzibar. Key determinants include timing of ANC initiation, parity, household income, partner support, and clinic environments. Strengthening community awareness on early booking, reducing financial barriers, and promoting male-friendly health services could improve ANC utilization and maternal health outcomes.\u003c/p\u003e","manuscriptTitle":"Factors Associated with Antenatal Care Service Utilization Under the Eight-Contact Visit Model in Zanzibar","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-02 13:31:44","doi":"10.21203/rs.3.rs-8216138/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewersInvited","content":"","date":"2025-12-04T08:36:20+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-11-28T09:58:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-28T00:46:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-28T00:46:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-11-26T20:50:57+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"26b8f38c-2368-42ca-8b8e-6cecc88833d0","owner":[],"postedDate":"March 2nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T13:31:44+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-02 13:31:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8216138","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8216138","identity":"rs-8216138","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}